Cases/Gastroenterology

Gallstones on an A&E Letter — Free SCA Practice Case

Woman with gallstones on her A&E letter who wants them out now

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12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

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Patient Profile

Full Name

Gwen Tremayne

Age

45 years

Consultation Type

Video

Age

Situation

Video Consultation. Routine appointment after an A&E attendance.

Reason for Encounter

"Seen in A&E at the weekend with tummy pain. Letter says gallstones. Would like to discuss getting them removed quickly."

Medical Records

●PMH: Nil.
●Medications: Combined oral contraceptive pill.
●Allergies: NKDA.
●Social: Caterer.

Recent Notes

●A&E letter, 5 days ago: Third episode in 7 weeks of right upper quadrant pain after food. Afebrile, Murphy's sign negative. Bloods including CRP, bilirubin, liver tests and amylase normal. Ultrasound: multiple gallstones, wall 2 mm, bile duct 4 mm. Biliary colic. Codeine with paracetamol supplied. Please refer to surgery.

Patient Script

For the friend playing the patient role

Character Overview: You are Gwen Tremayne, a 45 year old woman who has run her own catering business for eleven years, doing weddings, wakes and work lunches. You live with your husband Rhys, a delivery driver, and your son Kit, 17, who helps at weekend events. You have had three attacks of pain under your right ribs in seven weeks, each starting an hour or so after an evening meal. The third, on Saturday night, lasted four hours and Rhys drove you to A&E. The letter says gallstones and asks your GP to refer you for an operation. In eight weeks on Saturday you are catering a wedding for 140 guests at a barn venue, your biggest job ever, and you want the operation done before then. You are warm, quick and practical, the one everyone turns to when an event goes wrong. You sound impatient rather than frightened, and soften once you feel the doctor is on your side.

Opening Sentence: "Hiya, thanks for fitting me in. I ended up in A&E on Saturday night with that pain under my ribs again, and the letter says it's gallstones. Thing is, I've got a wedding for a hundred and forty people to cater in eight weeks, so I really need them out before then. Can you get me in for the operation quickly?"

History if Asked (Data Gathering Phase)

●How many attacks and when: "Three now. The first was about seven weeks ago after Sunday lunch, roast pork. The second about three weeks ago after a takeaway. Then Saturday, after a tasting evening for a client, all cheese and puddings."
●Where the pain is and what it is like: "Right under my ribs on this side, and it goes round into my back, under my shoulder blade. It's a constant tight pain, like a belt pulled in under my ribs. It doesn't come and go. I couldn't get comfy, I was pacing round the kitchen."
●How long each one lasted: "The first was a couple of hours, the second about three. Saturday's went on four hours and wasn't easing, so Rhys said that's it, we're going in." Always in the evening, an hour or so after eating, never in the day.
●Being sick, in between and since A&E (if asked): "I was sick once on Saturday. With the other two I just felt queasy. I'm completely fine in between. No pain at all since Sunday morning, I'm eating normally and I'm back at work."
●What she has taken for the pain (if asked): "The first two times, paracetamol and a hot water bottle. A&E gave me codeine ones, but they made me woozy and bunged me up. I've got about six left. I can't be woozy, I drive the van and I'm round hot oil all day."
●Diet and weight (if asked about eating, weight, or what might have caused it): "About six months ago I did one of those shake plans, about eight hundred calories a day. I lost just under two stone in eight weeks and stopped about four months ago. At work I taste all day, bits of pastry and sauces, then I have a big late dinner at home because I never sit down to eat at events."

Ideas, Concerns, Expectations

Gating note: Gwen does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for.

●Ideas: She sees the stones as a simple mechanical problem with a simple fix, and believes writing urgent on the letter will speed things up. "They're just stones sitting in there, aren't they? So take it out and job done. Pauline next door was in and out with hers inside a week, so I thought if you put urgent on the letter they'd get me in." If asked about Pauline: "She was really poorly, to be fair. Two days of pain, a temperature, and they kept her in on a drip and did it that same week." If asked what caused them: "I did wonder if it was those shakes. My sister said crash diets give you gallstones."
●Concerns: An attack in the middle of the wedding. "I'm the head cook. If I go down halfway through the main course, there's a hundred and forty people and a bride waiting. My whole business is word of mouth. One disaster like that and I'm finished."
●Expectations: An urgent referral today and the operation within the month. If asked what she will do if that cannot happen, her backup plan comes out: "Well, if you can't get me in, my plan was to go back to A&E next time it starts and tell them I'm not leaving until they take it out. That's what worked for Pauline."

If Asked: Medical History and Medications

Gating note: Gwen answers each of these plainly when the doctor asks about it.

●Other health problems, ulcers, indigestion, asthma, kidney problems, operations, allergies: "No, never anything like that. Never had an operation. No allergies. They said my bloods were all fine at A&E."
●Medicines and the pill: "Just my pill, and the codeine ones from A&E. No blood thinners, nothing over the counter. Same pill about six years, no bother."
●Periods, pregnancy, clots, migraines: "Regular on the pill. The pregnancy test at A&E was negative. No clots or migraines, nobody in the family either."
●Family: "Mum had her gallbladder out in her fifties, years ago. She was fine after."

Social History and Lifestyle Impact

●The wedding: "It's eight weeks on Saturday. A hundred and forty guests at a barn. They booked me a year ago and I've taken the deposit. On the day I'm on my feet fourteen hours, lifting trays and urns and driving the van."
●Lifestyle impact: "Since Saturday I've been on edge every evening, waiting for it to start. I took Kit to a tasting on Wednesday in case I needed driving home. It's not the money, it's my name. All my work comes from people recommending me."
●Home, alcohol, smoking, exercise: Rhys is supportive. "A gin and tonic a couple of times a month. I stopped smoking eighteen years ago. I'm on my feet all day."

If Asked: Associated Symptoms

●If asked about fever, shivering, yellow skin or eyes, dark urine, pale stools, itching, or black stools or blood: "No, none of that. Rhys would have noticed if I'd gone yellow."
●If asked about pain going straight through to the middle of the back, or being sick over and over: "It goes round to my shoulder blade, not straight through. And I was only sick the once."
●If asked about pain right now, her appetite, weight loss, bowels, heartburn, chest pain or breathlessness: "None at all. Appetite's fine. I only lost weight on purpose with the shakes. Bowels normal apart from the codeine. No heartburn."

Responses to Management (The Negotiation Phase)

●
If the doctor says they will refer her to the surgeons, or explains that no date or urgent label can be promised because of the wedding:
- ●Reaction: Relieved but straight onto timing. "Brilliant. How quick will that be? Will it be done before the wedding?" If told no date can be promised: "So I could still be waiting months from now? What's the point of the letter then?" She settles when shown what she can do. On choosing a hospital: "I didn't know I could pick. I'd drive an hour if it was quicker." On a cancellation list: "Do I tell the hospital or do you?" On paying privately: "How much? I'd have to talk to Rhys." If she asks about a tablet to dissolve the stones, she accepts a clear explanation.
●
If the doctor explains recovery, or life without a gallbladder:
- ●Reaction: A realisation. "Hang on. If they did it three weeks before, I might still be sore lifting urns on the day? That's no good either." She becomes open to having it done after the wedding if the attacks can be managed until then. "Can you manage without it, then? Mum seemed fine."
●
If the doctor offers pain relief for future attacks, or suggests more codeine:
- ●Reaction: Practical. "Nothing that knocks me out, please. That injection at A&E worked a treat, is there a tablet version? Do I take it as soon as it starts?" About codeine: "Those made me feel drunk. I can't drive the van or stand at the fryers like that."
●
If the doctor explains why going back to A&E to demand surgery would not work, or what leaving the stones could mean:
- ●Reaction: A bit defensive. "Well, it worked for Pauline." Once the difference is explained: "So she got it done quick because hers had gone bad. I don't want that, do I." Then: "Will it carry on like this until then? Could it turn bad like hers?" If the safety netting is vague: "Worse than four hours of that? Give me something I can actually go on."
●
If the doctor advises on diet, causes of gallstones, or the pill:
- ●Reaction: "I'm a caterer, I taste everything. Am I meant to live on lettuce for two months?" She engages with practical advice. If she has not mentioned the shakes: "Was it those shakes? Did I bring this on myself?" If crash diets are advised against: "I was going to do the shakes again before the wedding, actually." About the pill: "What's that got to do with my gallbladder? Is there another pill I can just swap to? I'm not having anything fitted with eight weeks to go."
●
If the doctor asks her to press on her tummy or check anything on camera, or helps her plan for the wedding day:
- ●Reaction: She declines politely. "I'd rather not, I've only got my phone propped up on the counter. I'm not in any pain now anyway. I can pop in if you need to see me." On a backup plan: "I suppose Dee, my main helper, could run the kitchen if I wrote everything down for her. I've never let anyone do that before."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Gwen has typical biliary colic with a clean A&E work up. She wants urgent surgery before an event eight weeks away and plans to demand an operation at A&E. The skill is to refer sensibly, be honest that no date can be promised, show her what she can do about the wait, protect her from the unsafe parts of her plan, and keep her working.
●Model answer: refer to general surgery for laparoscopic cholecystectomy, routine with the lengthening attacks recorded, and give the wedding date so unusable dates are avoided. Explain choice of hospital, short notice cancellations and recovery time, give a pain relief plan that suits her job, practical eating advice, clear safety netting, and a review in a few weeks. Spot the combined pill.
●Also acceptable: asking for an earlier appointment on clinical grounds because the attacks are lengthening, and a decision to have surgery after the wedding. Not acceptable: urgent priority with the wedding as the only reason, a suspected cancer pathway, or promising a date.

Recognising Uncomplicated Gallstone Pain and Reading the Letter

●NICE Clinical Knowledge Summaries (CKS, Gallstones, revised February 2026) describe steady right upper quadrant or epigastric pain, usually 30 minutes to 8 hours, often after a fatty meal and radiating to the right shoulder blade, with nausea or vomiting, and no fever or tenderness between attacks. Gwen fits.
●Each result in the letter tells you what has been looked for and not found. Normal temperature, white cell count and CRP, a 2 mm wall and negative Murphy's sign argue against acute cholecystitis. Normal bilirubin, ALT and ALP with a 4 mm duct argue against a duct stone, so no MRCP is needed (NICE CG188 reserves it for a dilated duct or abnormal liver tests). A normal amylase argues against pancreatitis.
●The letter's safety net ("return if fever, jaundice or pain that does not settle") is too vague to act on, and its medicine list includes her combined pill. Both are the GP's job to pick up.

Why Operate, and the Referral

●About 80% of people with gallstones never have symptoms and need no treatment. Once stones cause pain, CKS notes a persistently high risk of further attacks and of cholecystectomy, and complications such as cholecystitis, jaundice, pancreatitis and cholangitis become more likely. They remain uncommon in any one year, so the operation is worth having but not an emergency.
●NICE CG188 recommends offering laparoscopic cholecystectomy for symptomatic stones, as a day case when planned. Urgency is clinical judgement. A routine referral noting the lengthening attacks is appropriate, and asking for an earlier appointment on those grounds is defensible. The wedding is a reason to discuss choice and timing, not a reason to label the referral urgent, and never a reason for a suspected cancer pathway.
●The BNF states there is no evidence to support ursodeoxycholic acid for gallstones and lists frequent biliary colic as a contraindication; the dissolution dose is 8 to 12 mg/kg daily for up to 2 years. CG188 makes no recommendation for it, and it could not work before the wedding.

Waiting, Choice, Recovery and the A&E Shortcut

●In England most people referred by a GP can choose the hospital for the first appointment, including independent hospitals providing NHS care at no cost. Waits can be compared on the NHS My Planned Care website. Patients can tell the booking team they will take a short notice cancellation and which dates they cannot do. Self funded private surgery is the patient's choice, and the GP can provide a letter.
●NHS recovery guidance: most go home the same day, return to work after 1 to 2 weeks, longer with heavy lifting or long standing, and should not drive until they can do an emergency stop without pain. So an operation in the last few weeks before the wedding could leave her unable to work it. Choosing a date after the wedding is her decision once she has the facts. CKS signposts the NHS England tool "Making a decision about gallstones".
●NICE CG188 advises early laparoscopic cholecystectomy, within 1 week of diagnosis, for acute cholecystitis. That is why Pauline, with fever and two days of pain, was operated on quickly. An attack that settles with analgesia is usually sent home, so demanding surgery at A&E will not work. She should still attend with warning signs.

Pain Relief While Waiting

●CKS: for mild to moderate intermittent pain offer paracetamol or an NSAID, for example diclofenac, by mouth or rectally if nausea is a problem. For severe pain, intramuscular diclofenac 75 mg, repeated once after 30 minutes if needed, or an intramuscular opioid if diclofenac is unsuitable. Pain that cannot be managed in primary care needs emergency referral.
●NSAIDs relieve biliary pain better than antispasmodics and, in trials, reduce progression to cholecystitis, so taking one at the start of an attack is reasonable. BNF oral diclofenac is 75 to 150 mg daily in 2 or 3 divided doses. Check for peptic ulceration or bleeding, NSAID sensitive asthma, kidney impairment, heart failure, cardiovascular disease and anticoagulants. Gwen has none, and her eGFR is above 90.
●Codeine causes drowsiness and constipation. Driving while impaired by a medicine is illegal, and drowsiness is unsafe for someone who works with hot oil and knives.

Eating While Waiting

●NICE CG188 advises avoiding food and drink that trigger symptoms until the gallbladder or stones are removed. CKS suggests considering a low fat diet, which may prevent further pain in around 30% of people. For a caterer this means small tastes rather than whole portions, regular smaller meals instead of one large rich meal late at night, and avoiding known triggers.
●Rapid weight loss and prolonged fasting promote stones. CKS lists loss of more than 1.5 kg a week as a risk factor, and Gwen lost about 12.5 kg in eight weeks. Another very low calorie plan before the wedding is a poor idea. Hormone replacement therapy is also a listed risk factor, worth remembering at the menopause.
●After surgery CG188 says people should not need to avoid the foods that triggered symptoms, and should see their GP if eating causes new or persisting symptoms.

Contraception and Gallstones

●UKMEC 2025: combined hormonal contraception is category 3 with current symptomatic gallbladder disease, category 2 after cholecystectomy. Progestogen only pill, implant and levonorgestrel coil are category 2, and the copper coil is category 1. Starting the injection when major surgery is planned is category 3.
●UKMEC 2025 also advises stopping combined contraception preferably 4 weeks before major elective surgery lasting over 30 minutes, with alternative contraception arranged, and restarting at least 2 weeks after full mobilisation. Switching now removes that problem before a date is offered.
●A correctly taken combined pill can be switched to a progestogen only pill straight away with no extra precautions (CKS Contraception, progestogen only methods). Gwen wants no coil or implant before the wedding, so a pill swap fits. This is not the focus of the consultation and may need a separate appointment.

Safety Netting With a Clear Disposition

●Same day hospital assessment through A&E, or 999 if very unwell, for fever or shivering, yellow skin or eyes, dark urine or pale stools, or severe constant pain going through to the back with repeated vomiting (NHS website). These point to cholecystitis, obstructive jaundice, cholangitis (Charcot's triad of fever with rigors, jaundice and upper abdominal pain) or gallstone pancreatitis.
●An attack that does not settle within a few hours despite painkillers needs same day help. A&E, an urgent GP appointment or NHS 111 are all reasonable depending on severity, because CKS advises emergency referral when pain cannot be managed in primary care.
●She should not drive herself to A&E with these symptoms. "Come back if it gets worse" is not enough for someone who has had four hours of severe pain.

Common Mistakes in This Station

●Reading the letter for the word gallstones without checking what the results exclude, or missing the combined pill.
●Asking for urgent priority with the wedding as the only reason, or promising a date.
●Discussing the wait without offering choice of hospital, short notice cancellations or private care.
●Forgetting recovery time, so she aims for an operation that leaves her unable to work the wedding.
●Repeating codeine as the only painkiller for a woman who drives a van and works near hot oil.
●Leaving the A&E backup plan unchallenged, or overcorrecting so she avoids A&E with warning signs.
●Vague safety netting without symptoms or a place to go.
●Missing her plan to repeat a crash diet before the wedding.

Mapped to the RCGP curriculum topic: Gastroenterology.

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